Empirical Research on Spirituality. and Alcoholism: A Review of the Literature ARTICLES. Donna Leigh Bliss

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1 served.] ARTICLES University of Georgia School of Social Work. 305 Tucker Hall. Athens, GA Donna Leigh Bliss, PhD ( is Assistant Professor at the tuality are provided. Limitations of studies are examined and implications for social work research are discussed. doi:lo.l300/j160v07n04_02 [Article ABSTRACT. The apparent success of Alcoholics Anonymous and its coholism and spirituality in the latter part of the 20th century. Using plore how AA worked and ultimately led to more formalized research on al Tentative conclusions about the relationship between alcoholism and spiri Miller s suggested research framework, a review of empirical research was conducted on four roles of spiritual variables in alcohol abuse and recovery. spiritually based program of recovery in 1935 led early researchers to ex copies available for a fee from The Haworth Document Delivery Seri ice: HA WORTH. address: Website: abuse, social work, research KEYWORDS. Alcoholism, spirituality, alcohol dependence, alcohol <hrtp.//www.haworrhpress.com> 2007 by The Haworth Press. All rights re Empirical Research on Spirituality Journal of Social Work Practice in the Addictions. Vol. 7( Available online at A Review of the Literature 2007 by The Haworth Press. All rights reserved. doi: lo,1300/j160v07n04_02 5 and Alcoholism: Donna Leigh Bliss

2 6 JOURNAL OF SOCIAL WORK PRACTICE IN THE ADDICTIONS INTRODUCTION The roots of social work involvement in the treatment of alcohol problems run deep. In her seminal work on social diagnosis, Mary Rich mond (1917) characterized inebriety as a disease that required a medical diagnosis and a comprehensive treatment approach given the medical, mental, environmental, social, occupational, familial, and ancestral as pects involved in the malady. While social workers have continued to play an important role in the treatment of alcoholism, they have also be come more involved in research, administration, policymaking, and program development domains (Straussner, 2001). Given that alcohol abuse and dependence continues to be a serious problem that social workers are confronted with, either as a primary problem or as a con tributing factor to such issues as child abuse and neglect, domestic vio lence, and psychiatric disorders, the profession will continue to be at the forefront of attempts to better understand and ameliorate this problem. The idea that alcoholism was a moral failing was predominant in America until the early part of the 20th century (Morgan, 1999). Mor gan notes that numerous factors came together after World War Ito suggest that psychological or physiological factors might be more re sponsible for the cause of the alcoholism than moral issues. One of these factors was the impact of Alcoholics Anonymous (AA), which supported the notion that alcoholism was a disease and emphasized the role of spirituality in recovery from the problem (Miller & Kurtz, 1994). While the philosophy of AA has evolved over time, its asser tion that alcoholism was a three-fold illness with physical, mental, and spiritual components (Alcoholics Anonymous World Services, Inc., 2001) promised to have important implications for future research and practice. The apparent success of the AA program with seemingly hopeless al coholics sparked the interest of researchers in how AA worked and what was responsible for its effectiveness. Morgan (1999) notes that one of the earliest specialists in addictions, Harry Tiebout, MD, was in trigued with the success of AA with some of his more difficult patients. Subsequent research by Tiebout (1944) explained the transformational process brought about by AA by stating the central effect, therefore, of Alcoholics Anonymous is to develop in the person a spiritual state which will serve as a direct neutralizing force upon the egocentric ele ments in the character of the alcoholic (p. 472). The growing success of AA led Tiebout (1961) to assert that AA should be studied even though

3 Donna Leigh Bliss 7 its spiritually based approach did not follow accepted scientific practices. This early line of inquiry into the role of spirituality in the recovery from alcoholism ultimately led to more formalized and systematic re search beginning in the late 1970s (Morgan, 1999). Researchers began to develop conceptualizations of the relationship between spirituality and alcoholism that generally incorporated themes that emphasized ei ther the positive or negative aspects of alcohol use. Examples of posi tive conceptualizations include seeing alcohol use as a vehicle for transcending the existential dilemmas of life (Gregoire, 1995; Kurtz, 1979) and as a search for spiritual wholeness (Whitfield, 1985). In con trast, examples of negative conceptualizations include seeing the rela tionship with alcohol as becoming idolatrous in nature (Morgan & Jordan, 1999; Prezioso, 1987; Van Kaam, 1987), framing alcoholism as the antithesis of spirituality (Miller, 1998; Prezioso, 1987), and sug gesting alcoholism can be considered a form of spiritual insanity (Doweiko, 1999). Research interest grew in the I 990s with an increased focus on the re I ationship between 12-Step spirituality and Alcoholics Anonymous (Morgan, 1999). This led to an increased interest in examining the role that spirituality plays in the development of and recovery from alcohol ism (Kaskutas, Turk, Bond, & Weisner, 2003). In addition, the National Institute on Alcohol Abuse and Alcoholism [NIAAA) (2000), in collab oration with the Fetzer Institute, issued a request for applications in tended to support research to better understand the role of religiousness and spirituality in the prevention and treatment of and recovery from al coholism and alcohol-related diseases (p. 1). Taking place within the context of a growing global interest in spirituality (Derezotes, 2006), this explicit research interest by such a prominent government organi zation helped to legitimize the importance of increasing understanding of the multi-faceted relationship between alcoholism and spirituality in the new millennium. Some years earlier, Miller (1998) stated that more research was needed and suggested four areas where the impact of spiritual/religious variables on addictive disorders such as alcoholism could be examined. These were (I) as risk or protective factors for alcohol use or abuse, (2) as elements of the course of alcoholism such as spiritual or religious practices, (3) as dependent variables affected by alcohol abuse such as spiritual health or spiritual development, and (4) as components of the recovery process (p. 981).

4 The purpose of this paper is to review the research literature on the re 8 JOURNAL OF SO1AL WORK PRACTICE IN THE ADDICTIONS conclusions about this relationship and identify limitations in the research literature. databases such as EBSCOhost, PsycINFO, ETOH, Academic Search Premier, and Social Work Abstracts using various keyword combina ined spiritual variables as risk or protective factors for alcohol abuse, five examined spiritual variables as elements in the course of alcohol studies he cites concern such aspects of religion as religious involve ment, membership, and participation, rather than spiritual involvement. alcohol abuse among adolescents and college students, less research is peer-reviewed journals, and (5) explicitly focused on alcohol use, tions including spirituality, spiritual functioning, spiritual development, ships between spirituality and alcoholism was conducted with several Spirituality as Risk or Protective Factors Miller (1998), (3) used adults as participants, (4) were published in alcohol abuse, alcoholism, and alcohol dependence. Inclusion criteria (2) addressed at least one of the four relationship areas suggested by were studies that: (1) were empirical rather than conceptual in nature, suggested by Miller (1998). In addition, the paper will provide tentative lationship between spirituality and alcoholism using the framework protective factor against alcohol abuse. However, none were located abuse, and three examined spiritual variables as dependent variables spiritual variables as components of the recovery process, five exam affected by alcohol abuse. abuse, or dependence. Forty-four articles published between 1977 and 2004 that met inclusion criteria were located, Of these, 31 examined that examined spirituality as a risk factor. Moreover, while a larger body God, can also be a risk factor for alcohol abuse. of research exists on the role of spirituality as a protective factor against He also discusses the potential paradoxical nature of this relationship, volvement is a protective factor against alcohol abuse. Yet, most of the since some spiritual variables, such as having a negative conception of A comprehensive review of the research literature on the relation According to Miller (1998), there is strong evidence that spiritual in Five studies were located that examined the role of spirituality as a LITERATURE REVIEW

5 who abuse alcohol should be less spiritually active or involved with reli gion than those who do not abuse alcohol. However, the correlational nature of this argument does not indicate whether spiritual activity de creases during the course of alcoholism, whether persons who are less spiritually active are more vulnerable to alcoholism to begin with, or Miller (1998) argues that spiritual/religious involvement can be a protective factor against alcohol abuse. Therefore, because spirituality spiritual/religious practices, yet they primarily examined religious prac some combination of both. Two studies were located that examined how alcohol abuse affects tices rather than spirituality. For example, Curtis-Boles and Jenkins Monroe (2000) found that women who were abusing substances had lower church involvement at an earlier age and were more likely to cease their religious practices compared to non substance abusing The Role of Spirituality During the Course ofalcoholism per se. of cultural and spiritual coping in sobriety among a variety of Alaska the protective factor of religious involvement rather than on spirituality ery of those who already had a problem with alcohol. For example, Ha zel and Mohatt (2001) found in their two-part study on the importance available on its role among adults. Additionally, most studies focus on The five studies reviewed support the notion of the role of spirituality although findings suggest that personal characteristics such as age, gen der, and race/ethnicity may moderate this relationship (Staton, Webster, Hiller. Rostosky. & Leukefeld, 2003: Wood & Hebert, 2002). Spiritual Natives that interventions that incorporate cultural and spiritual dimen Interestingly, only one study was located that identified the impor tance of the role spirituality might play as a protective factor against re found that persons who had two years of recovery had significantly higher levels of spirituality compared to persons who continued to relapse. also found to be a protective factor, in addition to assisting in the recov sions of an Alaskan Native woridview are important for preventing al cohol abuse and in assisting in the recovery of those already afflicted with an alcohol use problem. lapse once sobriety had been attained. In this case, Jarusiewicz (2000) Donna Leigh Bliss 9 as a protective factor against alcohol use in adults (e.g., Stewart, 2001), ity that was consistent with specific ethnic and cultural woridviews was is not compatible with alcohol abuse, it logically follows that persons

6 10 JOURNAL OF SOCIAL WORK PRACTICE IN THE ADDICTIONS women. In addition, among the findings in a study by Roland and Kaskutas (2002), the combination of both church involvement and AA involvement were significant predictors of past 30-day sobriety com pared to church attendance alone. Three studies examined how alcohol abuse impacts the sense of meaning and purpose in life. For example, Carroll (1993) found that the practice of some AA-related activities, such as number of meetings at tended, is associated with higher purpose in life and length of sobriety. Brown, Ashcroft, and Miller (1998) identified ethnic differences in pur pose in life as American Indians were found to have the highest levels compared to Caucasians and Hispanics. Finally, Jacobson, Ritter, and Mueller (1977) found that women tended to have higher purpose in life scores than men after treatment completion, suggesting women may re spond differently than men to the treatment experience. The Influences ofalcohol Abuse on Spirituality Little research is available on the relationship between spirituality and alcoholism, although it is possible alcoholism can have a negative impact on spirituality in the same vein that it does onphysical and psy chological health (Miller, 1998). Three studies were located that exam ined, at least indirectly, aspects of this relationship and the findings do suggest that alcohol abuse can have a negative effect on spirituality. For example, Robinson, Brower, and Kurtz (2003), compared people in treatment for alcohol problems with a non-alcoholic sample on various aspects of spirituality, such as feeling God s presence, finding comfort in religion, desiring to be closer to God, and being touched by the beauty of creation. They found that these were scored higher by the treatment population. These findings were interpreted by the authors as evidence of what Jung calls spiritus contra spiritum, the idea that both alcohol problems and spiritual life may be motivated by similar ef forts to resolve suffering (p. 13). At best, the findings suggest that the impact of alcohol abuse may not be uniformly negative on all aspects of spirituality or that people find spirituality while in treatment. In a qualitative study of 50 men and women in a hospital alcoholism treatment program, McGovern (1986) identified spirituality as one of three categories of losses (external, internal, and spiritual) commonly associated with alcoholism. Yet, the lack of pretest data or a comparison group of persons without alcoholism makes it impossible to determine the degree of the loss attributable to the alcoholism rather than other fac

7 Donna Leigh Bliss 11 tors and whether these losses were more acute for persons with alcohol problems compared to those without. Spirituality in the Recovery Process Miller (1998) poses the logical question whether if spiritual involve ment is a protective factor against alcohol abuse and current alcohol abuse is associated with a lack of spiritual involvement, then will spiri tual-based interventions promote recovery from alcohol abuse? While Miller recognizes that there is limitej empirical evidence to support a predictive relationship between spirituality and recovery, the sizeable research literature examined does allow for some tentative inferences to be made about this relationship. However, the challenge lies in organizing the large number of studies that were reviewed in a manner that helps to shed more light on this relationship. In order to provide some clarity, the studies in this section were placed under two broad categories-those that examined AAI12-Step spirituality and those that examined spirituality that was not AA/l 2-Step-related. Of the 31 studies that were examined, 21 primarily addressed AA involvement and/or usage of AA s 12-step program of recovery, while 10 were not explicitly associ ated with either AA or its 12 steps. AA/12-Step Involvement Twenty-one studies (17 quantitative and 4 qualitative) examined var ious aspects of the impact of AAII 2-Step involvement on attaining and maintaining sobriety. These studies tended to fall under three catego ries: (1) 12-Step practices in traditional AA samples, (2) 12-Step prac tices in non-traditional AA samples, and (3) comparisons between AA and non-aa samples. 12-Step Practices in Traditional AA Samples. Twelve studies were located that examined different aspects of 12-Step practices empha sized by AA, including attending meetings, having a sponsor, and hav ing a spiritual experience. The samples in these studies tended to focus on primarily White, male, and middle class AA members. While a large body of the research supports the notion that involve ment in AA and its spiritually based program of recovery is associated with increased sobriety and improvement in quality of life (Carter, 1998; Kaskutas, Turk, Bond, & Weisner, 2003; Spalding & Metz, 1997; White, Wampler, & Fischer, 2001), which aspects of the AA program are responsible for these results is less understood. The studies re viewed present contradictory findings on the importance of attending

8 received. ethnic groups. ]2 JOL RNAL OF SOCIAL WORK PRACTICE IN THE ADDICTIONS consequences from drinking at intake and showed less abstinence dur Turk, Bond, & Weisner. 2003: Sandoz, 1999; Tonigan, Miller. & Connors, meetings, having a sponsor, working the steps. and having a spiritual higher levels of spirituality tend to have improved outcomes, such as experience in achieving sobriety, although, as a whole, AA s version of spirituality is associated with increased sobriety (Carter, 1998: Kaskutas, greater length of recovery and higher general recovery-oriented behav 2000). In addition, correlational research has shown that persons with levels of spirituality to start with. non-spiritual aspects of AA involvement can be more highly valued also possible that persons with improved outcomes already had higher iors, compared to individuals with lower levels of spirituality than the spiritual aspects of the program. For example, in a qualitative (Corringlon, 1989; White, Wampler, & Fischer, 2001). However, it is tendance at AA was not motivated by the perceived spiritual benefits. and Jason (1995) found that for over 70% of the participants, weekly at study of a 134 men living in an Oxford House, Nealon-Woods. Ferrari, ethnic/racial groups. or other marginalized populations. Seven studies ery, based on these samples, may not hold true for women, non-white Instead, more than half attended AA for the sense of fellowship they Therefore, any inferences about the role of AA participation in recov cism of research that employs samples of AA members is that AA mem ment on attaining and maintaining sobriety that were identified above since AA members tend to be primarily White, male, and middle class. bership does not necessarily reflect all persons with alcohol problems et al, 2003), women (Rush, 2000), gay men, couples, and non-white Tonigan, Miller. and Schermer (2002) found that atheists and agnostics cluded atheists and agnostics, specialty AA meeting attendees (Magura were located that examined the same aspects of AAII 2-Step involve had significantly less AA attendance compared to persons who consid ered themselves either spiritual or religious, yet there were no signifi ditional samples of AA members are investigated. For example, for the traditional AA samples, hut in non-traditional samples. These in tual status had higher rates of drinking, severity of dependence, and cant differences in days abstinent and drinking intensity among the groups. In contrast. individuals who were unsure of their religious/spiri Along a different vein, there is support for the notion that the 12-Step Practices in Non-Traditional AA Samples. A common criti The role of AA/12-Step involvement is not as clear cut when non-tra

9 Donna Leigh Bliss 13 ing and after treatment compared to the other groups. In another study of a sample of 35 married couples where both partners were members in 12-Step organizations, Hendricks, Caidwell. and Katz (2003) found a complex set of relationships between spiritual practices, marital satis faction and length of sobriety (p. 45). AA s Protestant-based conceptualization of spirituality can be at odds with other ethnic cultures that have differing woridviews on spiri tual and religious matters. For example, Morjaria and Orford (2002) found that recovery for White men in AA consisted of six steps (hit rock bottom, accept powerlessness, hand over will/control, deal with charac ter defects, develop faith, and have a new perspective), while the pro cess of recovery for South Asian men not in AA consisted of three steps (draw upon cultural values, use of prayer and going to temple, and reaf firmation of dormant religious beliefs. In general, recovery for the White men in AA was more spiritual in nature and was very consistent with AA s suggested spiritual program of recovery, while recovery for the South Asian men not only was more religious in nature, but also more consistent with their earlier religious beliefs. In addition, the meaning of spirituality and religion may differ de pending on sexual orientation. For example, a study of gay men in AA by Kus (1992) raised questions about whether a relationship with God or a Higher Power is at the root of spirituality or whether it is a manifes tation of spirituality. Kus also noted that by being able to separate the spirituality of AA from their anti-gay religious backgrounds, some of these men were better able to utilize AA in achieving sobriety. Finally, Horstmann and Tonigan (2000) raised the question whether AA groups differ in their spiritual behaviors and beliefs (i.e., extent God, spirituality or a Higher power. and/or prayer and meditation were discussed in a typical AA meeting, [p. 76] ). In a sample of two main stream. nonspeciality AA groups selected from 55 possible groups in a metropolitan area, the researchers found the groups differed signifi cantly in spiritual practices and beliefs. Co,nparisoiz Between AA and Non-AA Samples Only two studies were located that compared the role of AA s spiritually based program of recovery with non-spiritual programs of recovery and spontaneous remitters. While generalizations cannot be made based on such limited research, the findings of Li, Feifer, and Strohm (2000) indicate important differences between AA and a cognitive-behaviorally based pro gram of recovery on five of seven spiritual questions. In this study, the AA

10 14 JOUR 1M4L OF SOCIAL WORK PRACTICE IN THEADDICTIONS group had significantly higher scores than the spontaneous remitters group on (1) getting strength from religious/spiritual beliefs, (2) believing all good deeds are ultimately rewarded, (3) feeling there is an unseen source that provided strength to face life, (4) not believing prayer is a waste of time, and (5) believing there is life after death. It is unclear however, as to whether these differences resulted from the different treatment approaches or whether the differences existed in the two groups prior to treatment. Per haps people who attend programs other than AA are not as open to spiritual approaches to treatment and therefore select programs that do not have spirituality as a major component. Yet, in a qualitative study of seven AA members and six spontaneous remitters, Kubicek, Morgan, and Morrison (2002) found that both those who utilized AA and those who quit on their own attributed at least part of their success to some sort of higher power. Spiritual Practices Other than AAII2-Step Related While a substantial portion of the literature focuses on AA and its spiritually based program of recovery, ten studies were located that ex amined the role of spiritual practices in attaining and maintaining sobri ety other than those that are AAII 2-Step-related. These studies fall under two broad categories: (1) traditional mixed gender samples and (2) non-traditional samples such as women only, African Americans, adult children of alcoholics, and Native Americans. Traditional Mixed Gender Samples. Three studies were located that examined the role of non-aa spirituality in recovery in the traditional mixed gender samples that tend to reflect the demographic mix of AA as a whole (e.g., primarily male, middle class, Caucasian, Protestant). While a large body of research supports the role of AAJI2-Step partici pation in improved functioning and increased sobriety in traditional samples that are relatively representative of AA as a whole, the same conclusions cannot necessarily be made about the role of non-aa spiri tuality with similar samples. For example, while Pardini, Plante, Sherman, and Stump (2000) found a positive relationship between level of spirituality and improved life functioning in their sample of 236 per sons recovering from substance abuse, Ludwig (1985) found in a quali tative study of 29 spontaneous remitters with relative or absolute abstinence that although spiritual experiences were one of the factors for the decision to initiate recovery, cognitive rather than spiritual fac tors were cited in the decision to maintain recovery once it had been at tained. According to Ludwig it is fascinating that virtually all of the respondents, regardless of their diverse routes toward recovery, arrived

11 Donna Leigh Bliss 15 at a common cognitive destination: mental associations to alcohol with very unpleasant, sickening, humiliating or distasteful experiences of a personal nature (p. 57). Non-Traditional Samples. Seven studies were located that examined the role of non-aa spirituality and recovery in non-traditional samples. This included samples comprised of women only, adult children of al coholics who are also alcoholics, Native Americans, and African Amer ican women. The importance of spirituality in recovery from alcohol problems in these non-traditional samples tends to be supported. First, among the themes that help women remain abstinent from alcohol is one that con cerns being connected to and a part of a spiritual dimension (Hammond, 2002). Similarly, Brome, Owens, Allen, and Vevaina (2000), in a study of African American women, found that spirituality is significantly re lated to positive mental health outcomes. Second, in her study of recov ering alcoholics who were also adult children of alcoholics, Carroll (1999) found that persons with higher levels of spirituality and self-ac tualization tend to have improved life functioning compared to people with lower levels. Third, there may be differences in how important spirituality is in recovery depending on ethnicity. Two studies noted the importance that Native Americans place on spirituality in achieving so briety (e.g., Moss, Edwards, Edwards. Janzen, & Howell, 1985; Ed wards, 2003). However, caution in generalizing these results is called for, given the limited number of studies that were located and diverse conceptualizations of spirituality. TENTATIVE CONCLUSIONS FROM THE LITERATURE ABOUT THE REL4 TIOASHIP BETWEEN ALCOHOLiSM AND SPIRITUALITY The limited amount of research on the relationship between spiritual itv and alcoholism, other than as a component of the recovery process. allows for only tentative conclusions. I. Spirituality, and its role in recovery from alcoholism, is a multidi mensional construct. As such, it can be assessed in many ways and along different dimensions, including meaning and purpose in life, relationship with God or a Deity figure. personal values, locus of control, and spiritual well-being.

12 16 JOURNAL OF SOCIAL WORK PRACTICE IN THEADDICTIONS izations of spirituality, including confounding spirituality and religion, tations in the following areas: (I) inconsistent and unclear conceptual within the past two decades. this review of the literature identified limi While the body of research on alcoholism and spirituality has grown 10. Spirituality can play an important role in recovery from alcohol 4. Higher levels of spirituality are associated with improved function ing in many life areas. in addition to abstinence from alcohol abuse. 5. Alcoholism can have a negative impact on spiritual functioning, 8. Non-traditional AA samples (atheists and agnostics, women, gay men, non-whites) might not receive the same benefits from AA participa tion as traditional AA samples, although AA affiliation can be associ ated with improved abstinence and other psychosocial outcomes. 9. People who do not identify as being spiritual or religious do not re 7. Involvement with AA and practicing its spiritually based pro 6. While alcohol abuse can lead to a reduction in religious practices, 3. Spirituality generally can be a protective factor against alcohol for spiritual practices such as engaging in prayer and meditation. Also unclear is what criterion determines whether practices are volvement. relapse prevention skills, stress management skills, lifestyle changes, and cognitive coping skills are also helpful. There is less clarity about which aspects of AA, such as attend gram of recovery by individuals who are more representative of and religion are often used synonymously. 2. There is no universally agreed upon definition OF what spiritual ity is, nor on how it differs from religion. In addition, spirituality although this impact may not be uniformly negative. and ethnicity can moderate this relationship. abuse in adults, although personal characteristics such as age themselves either spiritual or religious. Also, AA s conceptual ceive the same benefits from AA affiliation as those who consider ated with increased sobriety and improvement in quality of life. considered spiritual or religious in nature. such as church attendance, it is less clear whether this is also true ization of spirituality can be at odds with other ethnic worldviews. sponsible for these outcomes. ing meetings, having a sponsor, and working the steps, are re AA as a whole (White, male, middle class, Protestant) is associ ism, although not the only role. Social support, religious in LIMITATIONS OF STUDIES

13 Donna Leigh Bliss 17 (2) limited research focus other than on the role of spirituality in recov ery, (3) limited research focus on ethnic differences, and (4) limited re search focus on women. Further discussion of these limitations follows. Inconsistent and Unclear conceptualizations of Spirituality One important limitation in the research on alcoholism and spiritual ity is the lack of consensus on what spirituality is, how it is defined (if it is defined at all), how it is measured, and the tendency to confound it with religion. First, while there does appear to be some agreement in the literature that spirituality involves relationships with self, others, and a greater transcendent reality, little agreement exists about whether this must also involve God or a Deity figure. Adding to this confusion is how more existential concepts such as meaning and purpose in life are discussed as aspects of spirituality. For example, Brown, Ashcroft, and Miller (1998) examined the relationship between the consumption of al cohol and alcohol-related consequences and purpose in life. Robinson, Brower, and Kurtz (2003) examined the experiential aspects of spiritu ality. White, Wampler, and Fischer (2001) related spirituality to a search for purpose and meaning in life, but also suggested spirituality could be developmental in nature. Second, compounding the difficulty in understanding what exactly spirituality is, most studies reviewed did not provide an explicit concep tual definition of the term. Those that did tend to differ from each other. For example, Jarusiewicz (2000) defined spirituality as positive rela tionships with self, with others, and with God or the universe, as evi denced by tolerance, gratitude, release, and humility (p. 106). In comparison, White, Wampler, and Fischer (2001) conceptually defined spirituality as an internal search for meaning and purpose that ulti mately enhances the person s relationship with God or a Higher Power (p.21). Third, consistent with the varying ways spirituality is conceptual ized, few studies provided explicit operational definitions of spiritual ity, while those that did tended to be quite different, For example, Carroll (1993) operationally defined spirituality as the extent of practice of AA s Steps 11 and 12 as measured by a step questionnaire developed by the researcher. In comparison, Rush (2000) operationally defined spirituality in terms of scores on the Spiritual Orientation Inventory. Fourth, while studies used a variety of scales to assess spirituality, in cluding the Brief Multidimensional Measure of Religiousness and Spir ituality, Spiritual Belief Scale, Spiritual Well-Being Scale, and Spiritual

14 18 JOURNAL OF SOCIAL WORK PRACTICE IN THE ADDICTiONS Orientation Inventory, some studies did not use existing scales at all, but created their own. For example, Magura et al. (2003) measured the portance of spirituality with 11 items they developed. Scores for spiri tual well-being (derived from the Spiritual Well-Being Scale) and importance of spirituality were then standardized and combined into an additive index the authors termed spirituality. Open-ended questions in qualitative studies were also used to operationally define spirituality. For example, Nealon-Woods, Ferrari, and Jason (1995) asked two open-ended questions to assess spirituality ( I) how spiritual aspects of AA assist in recovery attempts and (2) what are the motives for volvement in AA. Fifth, although spirituality and religion can overlap to some degree, they are different from each other. For example, Curtis-Boles and Jenkins-Monroe (2000) assessed spirituality with four questions that had more to do with religious practices than spirituality (e.g., Are you currently a member of a church or spiritual group? and How do you practice your religion?). Stewart (2001) confounded spirituality and ligion by combining influence of spirituality to use substances and religious beliefs into one variable. Unfortunately, the diversity in how spirituality is defined, measured, and often used synonymously with religion makes it difficult to general ize the results from different studies because the spirituality talked about in one study might be quite different from the spirituality exaniined in another. Limited Research Focus of Existing Research While the research literature on spirituality and alcoholism has grown substantially in the past two decades, the bulk of the research has focused primarily on the role of spirituality in the recovery from holism. Of the 44 studies identified in the literature review. 3 1 targeted aspects of this relationship. The limited research interest in other areas, such as how alcoholism affects spiritual development, practices, liefs, or attitudes may be attributed to the difficulty in assessing these lationships due to problems in being able to access pre-test data. For example, in order to examine how alcoholism affects spiritual develop ment, the researchers need access to data on subjects spiritual develop ment before they started to drink and then conduct a prospective study. In addition, numerous other factors such as psychiatric disorders, trauma backgrounds, and other addictive disorders such as compulsive gambling or compulsive overeating can also have an impact of spiritual- im in re alco be re

15 Donna Leigh Bliss 19 ity. The net result, though, is that important research questions are left unaddressed due to the challenges involved in exploring them. While it might be easier for researchers to continue to conduct re search on the role of spirituality in recovery, there are indications that social work researchers are beginning to explore other aspects of the re lationship between alcoholism and spirituality. For example, an explor atory study of 180 women and men early in substance abuse treatment conducted by Bliss (2005) investigated how the severity of alcohol de pendence affected spiritual well-being. Findings showed that as alcohol dependence becomes more severe, spiritual well-being is reduced after controlling for 11 demographic and alcohol/drug-related variables. The promising results of this recent examination of spirituality as a depend ent variable affected by alcohol abuse calls for the need for more focused research on this relationship despite the inherent challenges involved. Limited Research Focus on Ethnic Differences The majority of studies either utilized primarily Caucasian samples or did not explicate ethnic differences in their results when more ethni cally diverse samples were used. Only 8 of the 44 studies reviewed ad dressed ethnic differences in their results. Four of these eight studies used ethnically-diverse samples and reported ethnic differences in their results. The other four studies used non-caucasian samples. For exam ple, Hazel and Mohatt (2001) focused exclusively on a diverse group of Alaska Natives. Moss, Edwards, Edwards. Janzen, and Howell (1985) targeted Native Americans in their study. Brome, Owens, Allen, and Vevaina (2000) and Curtis-Boles and Jenkins-Monroe (2000) used a sample of African American women in their studies. Limited Research Focus on Women Women continue to receive a limited research focus as findings from many studies using mixed-gender samples did not explicate any gender differences. For example, of the 44 studies in the literature review, only 6 studies that used mixed-gender samples also reported gender differ ences in their findings, while 4 studies utilized women-only samples (e.g.. Brome. Owens. Allen. & Vevaina, 2000; Curtis-Boles & Jenkins Monroe, 2000; Hammond. 2002; Rush. 2000). Yet. given the variability in how spirituality was conceptualized in these studies. caution needs to be exercised in attempts to generalize the

16 results. While women typically can experience more adverse physio 20 JOURNAL OF SOCIAL WORK PRACTICE IN THE ADDICTIONS cently rediscovered spirituality and how it affects individuals and so ciety as a whole (Canda & Furman, 1999). Writers such as Canda, gender differences in alcoholism and spirituality does not allow for the biopsychosocial functioning of the person, the profession has only re same conclusions to be drawn concerning spirituality. Abuse and Alcoholism, 1999), the paucity of research that examined logical effects from alcohol use than men (National Institute on Alcohol ment perspective that emphasizes the importance of understanding the Nakashima, Burgess, Russel, and Barfield (2003) illustrate this grow ism Treatment Quarter/v and Journal of Studies on Alcohol. nificant expansion of entries in the 2nd edition of their bibliography on ing recognition of the need for inclusion of spirituality by noting the sig journal) (Staton, Webster, Hiller, Rostosky, & Leukefeld, 2003). The one of the limitations identified in literature review inconsistent and spirituality and social work. Furman (1999) and Carroll (1998) have begun to address these concep unclear conceptualizations of spirituality, including confounding spiri ferences between spirituality and religion and in their providing social tuality and religion. For example, social work writers such as Canda and tually based limitations in the literature in their examination of the dif lenge of conducting empirical research on spiritual variables as ele work-based conceptualizations of spirituality. ments of the course of alcoholism and as dependent variables affected example, social workers were a noticeable omission in the authorship of by alcohol abuse or in investigating ethnic differences and gender dif most of the 44 studies identified in the literature review with only five ferences in the relationships between spirituality and alcoholism. For Corrington, 1989; Moss. Edwards, Edwards. Janzen. & Howell. 1985; studies authored by social workers (Carroll, 1997; Carroll, 1999; most predominant journals for the remaining 43 studies were Alcohol Stewart. 2001) and only one was published in a social work journal (this While the social work profession has long held a person-in-environ The social work profession has taken a leadership role in addressing However, the social work profession has yet to tackle the bigger chal IMPLIGATIONS FOR SOCIAL WORK RESEARCH

17 Donna Leigh Bliss 21 However, it should be noted that this review of the literature primar ily focused on the relationship between spirituality and alcoholism rather than spirituality and drug addiction or other addictive disorders. Given the prominent role that social workers play in the addictions field as a whole, it is likely that social work researchers who do not focus ex clusively on alcoholism might have been left out of the review. CONCLUSION The trend toward focusing greater research attention on the role of spirituality in the recovery from alcoholism does not appear to be increas ing despite the call from Miller (1998) for a broader investigation of the complexity of this relationship. While more is understood about how spirituality impacts recovery efforts, less is known about how alcoholism affects spiritual practices, attitudes, behaviors, and development, espe cially during the course of the progression from problem drinking to ac tive alcoholism. Given social work s long involvement in treating alcoholism (Straussner, 2001), the paucity of research in these other areas has implications for treatment provision, as more holistic assessments of clients cannot he conducted and interventions that specifically target spir ituality cannot he made if spirituality is only superficially or inadequately included. An important question to be answered, then, is whether the social work profession, given its emerging interest in spirituality as a whole, will be come a leader in addressing the limitations in the literature on the multi faceted relationship between alcoholism and spirituality, or continue to remain a follower. REFERENCES Alcoholics Anonymous World Services. Inc. (2001 ). Alcoholics Anonymous: The story of how many thousands of men and women have recovered from alcoholism (4th ed). New York: Alcoholics A nonvmous World Services. Inc. Bliss. D. L. (2005). Impactofthe severity of alcohol dependence on the spirituality of women and men with alcohol use disorders. Unpublished doctoral dissertation. Lni ersity of Maryland Baltimore. Brome. J. M.. Owens. M. D.. Allen. K.. & Vevaina, T. (2000). An examination of spiri tuality among African American women in recover from substance abuse. Journal of Black Pnchologv, 26(4) ,

18 22 JOUR,V4L OF SOCIAL WORK PRACTICE IN THE ADDICTIONS Brown, J, M., Ashcroft. F. G.. & MiIlr, W. R. (1998). Purpose in life among alcohol ics: A comparison of three ethnic groups. Alcoholism Treatment Qua rterlv, 16(3), Canda, E. R., & Furman, L. D. (1999). Spiritual diversity in social work practice: The heart of helping. New York: The Free Press. Canda. E. R., Nakashima, M., Burgess, V. L., Russel. R., & Barfield. S. T. (2003). Spir itual diversity and social work: A comprehensive bibliography with annotations (2nd ed.). Alexandria, VA: Council on Social Work Education. Carroll, M. M. (1997), Spirituality, alcoholism, and recovery: An exploratory study. Alcoholism Treatment Quarterly, 15(4), Carroll, M. M. (1998). Social work s conceptualization of spirituality. Social Thought, 18(2), Carroll. M. M. (1999). Spirituality and alcoholism: Self-actualization and faith stage. Journal of Ministry in Addiction & Recovery, 6(1), Carroll, 5. (1993). Spirituality and purpose in life in alcoholism recovery. Journal of Studies on Alcohol, May Carter, T. M. (1998). The effects of spiritual practices on recovery from substance abuse. Journal of Psychiatric and Mental Health Nursing, , Corrington, J. E. (1989). Spirituality and recovery: Relationships between levels of spirituality, contentment and stress during recovery from alcoholism. Alcoholism Treatment Quarterly, 6(3/4) Curtis-Boles, H., & Jenkins-Monroe, V. (2000). Substance abuse in African American women. Journal of Black Psychology, 26(4) Derezotes, D. S. (2006). Spiritually oriented social work practice. Boston: Pearson. Doweiko, H. E. (1999). Substance use disorders as a symptom of a spiritual disease. In 0. J. Morgan & M. Jordan (Eds.). Addiction and spirituality: A multidisciplinan approach (pp ). St. Louis: Chalice Press. Edwards, Y. (2003). Cultural connection and transformation: Substance abuse treat ment at Friendship House. Journal of Psychoactive Drugs, 35(1), Gregoire. T. K. (1995). Alcoholism: The quest for transcendence and meaning. Clini cal Social Work Journal, 23(3), Hammond, A. E. (2002). Multi-method triangulation exploring the relationship be tween spirituality, power and change in women who have alcohol-related problems. Journal of Substance Use, 7, Hazel, K. L., & Mohatt. G. V. (2001). Cultural and spiritual coping in sobriety: Inform ing substance abuse prevention for Alaska Native communities. Journal ofcommu nity Psychology, 29(5), , Hendricks, V. M.. Caldwell, K. L.. & Katz. B. M. (2003). The relationships among spiritual practices. marital satisfaction. and length of sobriety, Alcoholism Treat meat Quarterly, 21(1), Horstmann. M. J.. & Tonigan, J. S. (2000). Faith development in Alcoholics Anony mous (AA): A study of two AA groups. Alcoholism Treatment Quarterly, 18(4),

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20 24 JOURNAL OF SOCIAL WORK PRACTICE IN THE ADDICTIONS National Institute on Alcohol Abuse and Alcoholism. (2000). NIH Guide: Studying spin tuality and alcohol. Retrieved January , from nih.gov/ grants/guide/rfe-files.rfa-aa html Nealon-Woods, M. A., Ferrari, J. R., & Jason, L. A. (1995). Twelve-Step program use among Oxford House residents: Spirituality or social support in sobriety? Journal of Substance Abuse, Pardini, D. A.. Plante. T. G., Sherman. A.. & Stump. J. E. (2000). Religious faith and spirituality in substance abuse recovery: Determining the mental health benefits. Journal of Substance Abuse Treatment, 19, Prezioso. F. A. (1987). Spirituality in the recovery process. Journal of Substance Treatment, 4, Richmond, M. E. (1917). Social diagnosis. New York: Russell Sage Foundation. Robinson. E. A.. Brower. K. J.. & Kurtz, E. (2003). Life-changing experiences, spiritu ality and religiousness of persons entering treatment for alcohol problems. Alcohol ism Treat,nent Quarterly, 21(4), Roland. E. J., & Kaskutas, L. A. (2002). Alcoholics Anonymous and church involve ment as predictors of sobriety among three ethnic treatment populations. Alcohol is,n Treatment Quarterly, 20(1), Rush. M. M. (2000). Power, spirituality, and time from a feminist perspective: Corre lates of sobriety in a study of sober female participants in Alcoholics Anonymous. Journal of the American Psychiatric Nurses Association, 6(6), Sandoz. C. J. (1999). The spiritual experience in recovery: A closer look. Journal of Minisrn in Addiction & Recovery, 6(2) Spalding. A. D.. & Metz. G. J. (1997). Spirituality and quality of life in Alcoholics Anonymous. A lcoholis,n Treatment Quarterly, 15(1) Staton. M.. Webster. J. M.. Hiller. M. L.. Rostoskv. S., & Leukefeld. C. (2003). An ex ploratory examination of spiritual well-being, religiosity, and drug use among in carcerated men. Journal of Social Work Practice in the Addictions, 3(3) Stewart. C. (2001). The influence of spirituality on substance use of college students. Journal of Drug Education, 31(4) Straussner. S. L. (2001). The role of social workers in the treatment of addictions: A brief histor. Journal of Social Work Practice in the Addictions. 1(l).3-9. Tiehout. H. M. 1944). Therapeutic mechanisms of Alcoholics Anonvmous.American Journal of Psychiatry Tiehout. H. M. (1961), Alcoholics Anonymous An experiment of nature. Quarterly Journal of Studies on Alcohol, Tonigan. J. S.. Miller. W. R.. & Connors. G. J. (2000). Project MATCH client impres sions about Alcoholics Anonymous: Measurement issues and relationship to treat ment outcomes. Alcoholism Treatment Quarterly, 18(1 ) Tonigan. J. S.. Miller. W. R.. & Schermer. C. (2002.Atheists. agnostics and Alcohol ics Anonymous. Journal of Studies on Alcohol. September Van Kaam. A. (1987). Addiction: Counterfeit of religious presence. Studies in Forma tive Spirituality, V1ll(2),

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